Considerations for Choice of Cranioplasty Material for Pediatric Patients.

INTRODUCTION: Optimal material and timing of cranioplasty in the pediatric population continue to be debated. Autologous and alloplastic materials have various indications for use and risk factors for complications. METHODS: A single-center retrospective cohort study was undertaken of all pediatric patients who underwent cranioplasty with any material from 1991-2021. RESULTS: 149 cranioplasty implants were included. Younger age (6 years old or under), a diagnosis of craniosynostosis as reason for implant, use of autologous bone, and shorter times to cranioplasty were predictive of need for revision surgery. No factors studied had a statistically significant impact on rate of removal of implant at time of revision surgery. CONCLUSION: Autologous and alloplastic cranioplasty materials both have good outcomes with low rates of revision surgery in the pediatric population. Alloplastic implants may be considered in the setting of infection as reason for craniectomy given the lower rate of revision surgery and need for removal. Patients with craniosynostosis as reason for cranioplasty have a higher risk of requiring revision or additional surgeries, regardless of implant used.

Reconstruction of Scalp Wounds in Patients With Excoriation Disorder.

Excoriation or skin picking disorder is described as compulsive picking of the skin that cannot be explained by an underlying dermatological condition. There are unfortunately no clear guidelines in the literature for reconstruction of wounds in this patient population. The authors describe the cases of 2 patients with the skin picking disorder who underwent free flap reconstruction for scalp wounds, which were complicated by wound recurrence due to manipulation of the surgical site. The literature is reviewed in detail, and steps to potentially prevent recurrence in this patient population are discussed.

Technical Considerations and Clinical Applications of the Free Anterior Branch Split Latissimus Dorsi Flap.

BACKGROUND: The free anterior branch split latissimus dorsi flap has a reliable anatomy and advantages over the traditional latissimus dorsi flap. By preserving the posterior branch of the thoracodorsal nerve, morbidity at the donor site is reduced, preserving shoulder strength. METHODOLOGY: The purpose of this article is to review our experience with the split latissimus flap, describe our surgical technique, and finally review representative cases of reconstruction in different anatomical regions. RESULTS: From April 2017 to October 2020, 39 free split latissimus flaps were performed at a single center. Flaps were performed for coverage in the upper extremity (n = 2), lower extremity (n = 32), and head and neck (n = 5). Flap success rate was 97.4%. Mean dimensions of the flap were 17.0 × 8.3 cm, with a mean area of 145 cm2. CONCLUSIONS: The flap has a broad application and can be utilized in many different reconstructive scenarios including for coverage of defects in the extremities, trunk, and head and neck.

Objective predictors of intern performance.

BACKGROUND: Residency programs select medical students for interviews and employment using metrics such as the United States Medical Licensing Examination (USMLE) scores, grade-point average (GPA), and class rank/quartile. It is unclear whether these metrics predict performance as an intern. This study tested the hypothesis that performance on these metrics would predict intern performance. METHODS: This single institution, retrospective cohort analysis included 244 graduates from four classes (2015-2018) who completed an Accreditation Council for Graduate Medical Education (ACGME) certified internship and were evaluated by program directors (PDs) at the end of the year. PDs provided a global assessment rating and ratings addressing ACGME competencies (response rate = 47%) with five response options: excellent = 5, very good = 4, acceptable = 3, marginal = 2, unacceptable = 1. PDs also classified interns as outstanding = 4, above average = 3, average = 2, and below average = 1 relative to other interns from the same residency program. Mean USMLE scores (Step 1 and Step 2CK), third-year GPA, class rank, and core competency ratings were compared using Welch's ANOVA and follow-up pairwise t-tests. RESULTS: Better performance on PD evaluations at the end of intern year was associated with higher USMLE Step 1 (p = 0.006), Step 2CK (p = 0.030), medical school GPA (p = 0.020) and class rank (p = 0.016). Interns rated as average had lower USMLE scores, GPA, and class rank than those rated as above average or outstanding; there were no significant differences between above average and outstanding interns. Higher rating in each of the ACGME core competencies was associated with better intern performance (p < 0.01). CONCLUSIONS: Better performance as an intern was associated with higher USMLE scores, medical school GPA and class rank. When USMLE Step 1 reporting changes from numeric scores to pass/fail, residency programs can use other metrics to select medical students for interviews and employment.

Is Thoracodorsal Nerve Transection Needed in Latissimus Dorsi Breast Reconstruction?

PURPOSE: Latissimus dorsi (LD) breast reconstruction is of proven efficacy. Advantages of thoracodorsal nerve transection are potential prevention of muscle spasticity/movement; disadvantages are possible long-term muscle atrophy and volume loss. This study's purpose is to provide data that would support or refute nerve transection. METHODS: A retrospective study of all LD breast reconstruction patients from 2011 to 2017 was done. Total number of flaps was identified, as was thoracodorsal nerve transection. Outcomes were noted for symptomatic muscle spasticity/involuntary movement, and complications inclusive of hematoma, seroma, and capsular contracture. RESULTS: A total of 125 patients had 170 flaps. Eighty-one flaps had nerve transection; 89 did not. These cohorts had no differences in comorbidities, indications of surgery (cancer vs prophylactic), irradiation, delayed/immediate reconstruction, and use of expanders. Symptomatic muscle movement/spasticity was not significantly different: 3 (3.7%) of 78 in transection and 5 (5.6%) of 84 in nontransection (P = 0.55, χ). Incidence of seroma in the transection group was notably higher (18/81; 22% vs 12%) but not statistically significant (P = 0.09, χ). No differences existed in all other outcomes. CONCLUSIONS: Symptomatic spasticity or involuntary muscle movement occurs in a small number of patients with LD breast reconstruction and is not affected by thoracodorsal nerve transection. Movement after transection is likely due to aberrant nerve innervation and reinnervation. The absence of movement without transection is due to disruption of muscle position and origin after transfer. Seroma formation may be affected by increased axillary dissection required for nerve transection. These data do not support nerve transection, and therefore, it is not recommended.

Practice Trends in Plastic Hand Surgery: An Evaluation of Cases in the TOPS Database.

Background: Previous studies have sought to outline the clinical practice of hand surgeons with plastic surgery training backgrounds. Still, minimal data exist characterizing the scope of hand surgery among plastic surgeons, regardless of the subspecialty fellowship training. Methods: All hand procedures logged in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database from 2002 to 2016 were identified by the Common Procedural Technology (CPT) code and/or "upper extremity" anatomic classification. Trends in the total number and types of procedures, facility type, admission type, modes and providers of anesthesia, and patient demographics were reviewed. Results: A total of 182,137 hand procedures performed on 82,811 patients during the 15-year period were reviewed. Sixty-eight percent of procedures involved soft tissue only, and 22.7% involved only bone and/or joint. The most common procedure categories included the following: wound closure/coverage (15.8%), debridement/drainage (15.3%), nerve (13.2%), tendon (12.9%), and fracture/dislocation (12.9%). Ambulatory and office-based procedures increased over time, along with the use of local anesthetic, as well as a transition from the procedural surgeon providing anesthesia to the use of anesthesiologists and nurse anesthetists. In addition, hand procedures have remained a considerable proportion of all logged procedures but have seen a steady decline since 2014. Conclusion: Plastic surgeons play an important role in the field of hand surgery, performing a wide variety of procedure types, which has remained stable over time. The trends in facility type and anesthesia characteristics have, however, varied.

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps.

BACKGROUND: The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap. METHODS: Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed. RESULTS: A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder. CONCLUSIONS: Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Contemporary Analysis of Rhytidectomy Using the Tracking Operations and Outcomes for Plastic Surgeons Database with 13,346 Patients.

BACKGROUND: Rhytidectomy is a popular procedure for facial rejuvenation, but an up-to-date, comprehensive, and broadly representative appraisal is lacking. METHODS: A cohort of patients undergoing rhytidectomy between 2008 and 2016 was identified from the Tracking Outcomes in Plastic Surgery database. Perioperative data and patient characteristics were analyzed with respect to adverse events. Multivariate logistic regression was used to identify association of complications with various risk factors. RESULTS: A total of 13,346 patients with a mean age of 60 years underwent rhytidectomies and a total of 31,206 Current Procedural Terminology procedures. Most were healthy women with an American Society of Anesthesiologists class of 1 or 2 (98 percent). On average, 2.3 procedures were performed in 3.8 hours per patient, and blepharoplasty was the most common adjunctive procedure. Fifty percent of operations were performed in office-based settings, and general anesthesia utilized in 63 percent of cases. The incidence of adverse events was 5.1 percent, with hematomas and infections as the most frequent surgical complications. Male gender, obesity, current smoker, duration, combined procedures, general anesthesia, and office-based surgery were associated with increased odds of adverse events. CONCLUSIONS: This is the largest outcomes analysis of face-lift surgery in a patient population solely representative of board-certified plastic surgeons. Rhytidectomy is a very safe procedure when performed by board-certified plastic surgeons. Nevertheless, risk factors for complications are identified, several of which can be affected by surgeon choice of surgical venue, additive procedures, duration of operation, and type of anesthetic. The study provides a standard reference for professionals when counseling patients and in guiding clinical practices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.